info@legaladvancegroup.com
 
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Attorney Information
     
 
 
Advance Request Application
 
Please take a few minutes to complete the form below. We will handle the rest for you! We’ll obtain the necessary documents from your lawyer and determine the no-risk, non-recourse funding amount you qualify for. You may also call an Legal Advnace Group Inc. at (888) 629-1122 with questions or to apply by phone.
 
Please fill out as much information as possible for a quicker response time to your advance
 
Contact Information Attorney and Case Information
First Name: *
Last Name: *
Date of Birth: * * *
Home Address: *
City: *
State:
Zip: *
Phone: * * *
Fax: * * *
Email: * *
Social Security No: *
Marital Status: Married Single Divorced
   
Firm Name: *
Address: *
City: *
State:
Zip: *
Phone: * * *
Fax: * * *
Attorney Name: *
Attorney E-mail: * *
Contact No: *
Are You The Original Attorney? Yes No
Case Manager Name: *
Case Manager Email: * *
 
 
Accident Information
(Kindly Provide all Applicable Information)
 
Type of Accident:
Date, Time of Accident of Injury:
Address where Accident of Injury Occurred:
Name (s) of Defendant (s)
Police Report: Yes No
Please provide any additional information
CASE DETAILS: Describe the facts concerning the accident (Theory of Liability) and cause of your injury.
STATUS OF LIABILITY: (Please Explain, with dates if applicable)
Accepted Date Accepted:  
Pending      
Denied      
Settled Date Settled:  
Lawsuit Filed Yes No    
 
 
Injury Information
Did your injury require surgery? (If yes, Please describe) Yes No
First Date of Treatment:
Date of Last Treatment:
Was An MRI Taken? Yes No
MRI Results:
Were you an Inpatient at a Hospital?
Is your Injury Permanent? Yes No
Did you have any Pre-Existing Conditions that were Affected by the Accident? Yes No
Have Any Medical Bills been paid Yes No
Total Medical Bills To-Dated
Future Medical Costs (estimate)
Will your Injury Require Further Surgery? Yes No
Property Damage: (Provide Estimates and Pictures)
 
 
Insurance and Settlement Information
Defendant’s Carrier:
Address:
City:
State:
Zip:
Claim Number:
Policy Number:
Coverage:
Adjuster’s Name:
Phone:
E-Mail Address:
Plaintiff’s Carrier:
Address:
City:
State:
Zip:
Claim Number:
Policy Number:
Coverage:
Adjuster’s Name:
Phone:
E-Mail Address:
 
 
WAGE LOSS
Wage Loss to Date: Yes No
How Much?
Future Anticipated Lost Wages:
 
 
SETTLEMENT OFFERS
Last Settlement Demand from you to Defendant
Last Settlement Offer from Defendant to you
Your Estimated Value of the Case
Date:
Date:
Estimated Date to Settle:
 
 
LIENS AND ASSIGNMENTS ON YOUR CASE:
Please Indicate the Liens and Assignments , if any, on your Case. If you do not have a Lien, Write “none” in the Applicable Box
Contingency Fee % Prior to Lawsuit
Insurance Liens:
Prior Advances on Case:
Name of Advance Company
Contingency Fee % Post Lawsuit
Medical Liens:
Workman’s Compensation
Other Liens or Assignments
 
 
ADDITIONAL INFORMATION: Have you ever...
Been Convicted of a Felony? Yes No
Been a Defendant in a Case? Yes No
Declared Bankruptcy? Yes No
Changed Attorneys in this Case?
Obtained a Prior Advance on this Case?
Filed a Lawsuit for an injury to your body that was in the same area Injured in this accident?
If you Answered “ Yes” to Any of the above Questions, Please Explain.
 
 
Certification and Authorization
The information provided in this application is true, accurate and complete to the best of my knowledge and belief. I authorize my attorney to release information pertaining to my claim for personal injuries, in which he/she is my representative, to Legal Advance Group Inc. including, but not limited to, personal information , medical reports, surgical reports and insurance information.
 
 
 
Disclaimer: Not available to Residents of Arkansas, Colorado , Kansas , Maryland or North Carolina.
 
 
Legal Advance Group Inc. / 16200 Ventura Blvd., Suite 300 Encino, CA 91436 — Visit Blog Tel: 888-629-1122 / Fax: 888-256-0809
Note: Contingent legal funding is a legal and ethical financial resource for law firms and its clients. Lawsuit advances are not loans since the funds advanced are entirely
non-recourse. The transaction is a non-recourse purchase of a portion of the proceeds of a potential future case award or settlement. A loan is a transaction that always
requires repayment. However, legal funding only requires repayment if the plaintiff receives a favorable cash settlement award. If the plaintiff loses their case, they do not
repay the funded amount or any interest.